Seizures and Epilepsy

Seizures and Epilepsy

Kathy M. England

Madona D. Plueger


This chapter focuses on adults with epilepsy and the nurse’s role in assisting patients to self-manage in the community setting and in caring for hospitalized patients with a seizure disorder. Although seizures and epilepsy are common in children, the special considerations related to children with these conditions are not addressed in this chapter. Other resources should be consulted for specific information on childhood and adolescent epilepsy.

People with epilepsy come into contact with nurses in many diverse settings along the health care continuum: schools, group homes, clinics, acute care hospital units, emergency departments (EDs), and intensive care units. The nurse-patient relationship will vary based on the care setting and the unique needs of the patient. Patients come in contact with the health care system in many ways. Whether providing education for self-management of their disorder or seizure first aid, sharing observations with the health care team to help diagnose the epilepsy, or providing direct patient care during seizures, there will be a caring nurse who will need to know about epilepsy and how it affects each patient. The focus of this chapter centers on care of the patient with epilepsy who is managed in the community by a primary care provider or a neurologist as well as care of the hospitalized patient with epilepsy. The patients and their family are at the center of this team as participators in their care. Epilepsy is often a lifelong disorder and education is required throughout the lifespan.

Primary care providers, neurologists, and nurse practitioners in the community manage many patients with epilepsy. Those with refractory epilepsy may be referred to an epilepsy center where an epileptologist and a multidisciplinary team provide comprehensive management, addressing the many issues and needs of these patients. Nurses and advanced practice nurses are key in providing direct care, promoting self-management, and educating patients and their families so that they can live the most healthy and productive lives possible.


The ED can be the entry of care for patients with a first-time seizure, as well as for those with an established diagnosis of epilepsy. Close to 5% of the population of the United States will have at least one seizure that occurs without the presence of fever in their lifetime. Providers evaluate and treat patients acutely in the hopes of preventing further seizures or related complications. The emphasis is on identifying the underlying cause of the seizure, initiating treatment, and determining the need for additional evaluation. Nurses who practice in a hospital are likely to care for a patient who has a seizure secondary to metabolic imbalances, vascular abnormalities, or infections; it is important for them to be able to identify the various types of seizures that may occur. These types of seizures are partial or generalized in onset. Providing descriptive information about witnessed seizures will assist the team in diagnosing and treating the disorder.


Seizures and epilepsy have been classified for clinical and research purposes using several different forms. Most classification systems are complex and cumbersome to use. In 1981, the International League Against Epilepsy (ILAE) published a modified version of the International Classification of Epileptic Seizures that continues to be a useful classification system (Table 28-1).3

The following section briefly discusses partial and generalized seizures. Tonic-clonic seizures, as examples of generalized seizures, are described in greater detail because they are so common. Table 28-2 describes the major subtypes of partial and generalized seizures, and Table 28-3 classifies partial seizures by cerebral lobe involved.


  1. Partial (focal, local) seizures

    1. Simple partial seizures (consciousness not impaired)

      1. Focal motor (with and without jacksonian march)

      2. Somatosensory or special sensory symptoms (e.g., simple hallucinations such as tingling, light flashing, buzzing)

      3. With autonomic symptoms (e.g., epigastric sensation, pallor, flushing)

      4. With psychic symptoms (disturbances of higher cerebral function)

    2. Complex partial seizures (with impairment of consciousness)

      1. Beginning as simple partial seizures and progressing to impairment of consciousness

      2. With no other features

      3. With features as in simple partial seizures

      4. With automatism

    3. With impairment of consciousness at onset

      1. With no other features

      2. With features as in simple partial seizures

      3. With automatism

    4. Partial seizures evolving to secondarily generalized seizures

      1. Simple partial seizures evolving to generalized seizures

      2. Complex partial seizures evolving to generalized seizures

      3. Simple partial seizures evolving to complex partial seizures to generalized seizures

  2. Generalized seizures (generalized bilateral without focal onset)

    1. Absence seizures

    2. Myoclonic seizures

    3. Clonic seizures

    4. Tonic seizures

    5. Tonic-clonic seizures

    6. Atonic seizures

  3. Unclassified epileptic seizures (including all seizures that cannot be classified due to inadequate or incomplete data and some that defy classification)

From: Commission on Classification and Terminology of the International League Against Epilepsy. (1981). Proposal for revised clinical and electroencephalographic classification of epileptic seizures. Epilepsia, 22, 489-501.

Recent recommendations have been provided for updates of the classification system (Table 28-4). Recommendations attempt to simplify classification to improve understanding of seizure classification and focus on guidelines instead of complicated descriptive terms. Currently, these are only recommendations and gradual acceptance will be required for eventual changes in the classification system.8

Partial Seizures

Partial-onset seizures are also referred to as focal seizures and begin as electrical disturbance in defined, localized areas of the brain. This form of seizure includes over 50% of the partial-onset form of seizures. The complexity of the seizure makes it difficult to diagnose, and the seizures may go unrecognized. Complex partial seizures are more resistant to treatment than generalized seizures.9

There are three types of partial seizures: simple, complex, and complex seizures evolving into secondarily generalized seizures. Simple and complex seizures are distinguished on the basis of consciousness. In simple partial seizures, consciousness is not impaired; in complex partial seizures consciousness is impaired. The four subcategories of simple partial seizures are named for the areas of their presenting symptoms. These include motor, sensory, autonomic, and psychic seizures.

Seizures affecting the motor area can include rhythmic twitching of extremity or isolated muscle group; those affecting the sensory area can include sensory disturbance to an isolated part of the body. Those affecting the autonomic area can include unusual smell, and fear of panic. Visual and auditory hallucinations can occur.9

Complex partial seizures include both complex symptomatology and impaired consciousness. The patient can stare blankly into space, be mute or speak nonsensically, or have automatisms such as lip smacking, chewing, or picking at clothing. Partial seizures can evolve into secondarily generalized seizures. These seizures are further categorized based on the type of partial seizure that preceded the generalized seizure (i.e., simple partial seizure only, complex partial seizure only, or simple partial seizure evolving into complex partial seizure).7 Patients who experience secondarily generalized events often demonstrate a disturbing moan with convulsive movements in extremities.

Generalized Seizures

There are six categories of generalized seizures: absence, myoclonic, clonic, tonic, tonic-clonic, and atonic. Each seizure type has characteristic clinical and EEG findings that are outlined in Table 28-2. The absence seizure is subdivided into typical and atypical absence seizures according to the presence of different EEG patterns and clinical presentation. Clinically, atypical absence seizures have a less abrupt onset and termination and are of a longer duration. The most common type of generalized seizure is the tonic-clonic seizure, formerly called the grand mal seizure.





Partial Seizures

Simple partial seizures

  • Motor

  • Symptoms depend on the motor region activated.

  • May remain focal or may spread to other areas on the motor strip, a process called “march”; seizures called jacksonian seizures. For example, the seizure may begin in the fingers of one side, and march to the hand, wrist, forearm, and arm on the same side of the body. The particular sequence of involvement is helpful in locating the epileptic foci on the motor strip in the hemisphere opposite the convulsive movement.

  • Focal motor attack may cause head to turn to side opposite epileptic foci.

  • Todd’s paralysis may result; lasts minutes to hours.

  • Continuous focal motor seizure is called epilepsia partialis continua.

Applies to all simple partial seizures: may show abnormal discharges in a very limited region; seizures originating from deep structures may not be noted with scalp electrodes.

  • Sensory

  • Arise from cortical sensory strip.

  • Usually feels like “pins and needles” or numbness; sometimes, spatial disorientation.

  • May march to other areas or may become a complex partial or generalized tonic-clonic seizure.

  • Special sensory symptoms may include visual seizures such as flashing lights or visual hallucinations, auditory seizures with various sounds, gustatory sensations such as metallic taste or primary tastes (salty, sweet, sour, or bitter), or vertigo and floating sensations.

  • Autonomic

  • May occur as simple partial seizures.

  • Psychic

  • Disturbance in a higher-level function (i.e., distortion of memory), distorted time, feeling of déjà vu, illusions, depersonalization, or hallucinations.

  • Usually occur with impairment of consciousness and become complex partial seizures.

Complex Partial Seizures

One category

  • Only symptoms may be impaired consciousness or it may progress to include automatisms; note automatisms may occur in partial or generalized seizures.

  • Simple partial seizure followed by impairment of consciousness resulting in a complex seizure with motor, sensory, autonomic, or psychic symptoms as described above.

All complex seizures: generalized 2-4 Hz spike waves

Partial Seizures Evolving to Secondarily Generalized Seizures

One category

Includes seizures that may evolve into generalized seizures: simple partial, complex partial, or simple partial evolving into complex and then to generalized seizures.

Generalized Seizures

  • Absence seizures

Note: may be seen along with tonic-clonic seizures

Typical absence seizures: common in children; characterized by brief interruption in consciousness without loss of postural control. Typically, there is an interruption of activity with a momentary lapse of consciousness lasting 3-30 secs. If talking, the speech stops or slows; if eating, the hand and mouth stop, and if patient is called, there is no response.

Typical absences: 3-Hz spike-wave complexes with abrupt starts and stops

  • During an attack, the eyes may appear vacant, stare, or roll upward; the eyelids may twitch.

  • Seizures occur a few times to hundreds of times per day; person may not be aware of them.

  • People who have several attacks daily most often experience difficulty in learning or employment because of inattention.

Atypical absence seizures—the lapse of consciousness is usually of longer duration and less abrupt in onset; more obvious motor signs.

Atypical absences: ≤2.5 Hz; slower spike-and-wave pattern, and more irregular

  • Myoclonic seizures

  • Sporadic jerks that are sudden, brief; contractions that are usually symmetric.

  • When confined to one area, it may be the face and trunk; one or more extremities; an individual muscle; or a muscle group.

  • Myoclonic jerks are rapidly repetitive or relatively isolated.

  • Common around time of sleep or awakening; must be differentiated from myoclonic jerks of nonepileptic myoclonus.

Bilateral, generalized epileptiform discharges, typically polyspikes

  • Clonic seizures

  • Repetitive, rhythmic clonic movements that are bilateral and symmetric.

Associated with symmetric spike-wave complexes

  • Tonic seizures

  • Stiffening of the musculature, mostly of the body, but may also involve the arms.

Low-voltage paroxysmal fast activity (10 Hz)

  • Atonic seizures

  • Abrupt loss of postural muscle tone; lasts 1-2 secs.

  • Consciousness is briefly impaired, but usually there is no postictal confusion.

  • Common in children.

Generalized epileptiform discharges (spikes, spike-wave complexes)

  • Tonic-clonic seizures

  • Most common of the generalized seizures.

Fast high-voltage spikes seen in all leads

Unclassified Epileptic Seizures

One category

This group includes all seizures that cannot be classified because of inadequate or incomplete data. This self-explanatory category is a catchall for seizures that do not conform to any of the other headings.

Description of Generalized Tonic-Clonic Seizures

A tonic-clonic seizure progresses through distinct phases including the prodromal, tonic, clonic, and postictal phases. The prodromal phase of irritability and tension may precede the seizure by several hours or days. Some individuals experience an aura, whereas in others the seizure begins without warning. Characteristically, the tonic-clonic seizure begins with a sudden loss of consciousness. Neuronal hyperexcitation spreads to the subcortex, thalamus, and upper brainstem, and consciousness is suddenly lost. In the tonic phase, there is a major tonic contraction (increased tonus) of the voluntary muscles so that the body stiffens with legs and arms extended. If standing, the person falls to the ground. The jaw tightens, teeth clench, and the tongue or inner cheek may be bitten as a result. A loud, low ictal cry is heard as tonic contraction of the diaphragm and intercostal muscles force air through the contracted larynx. The patient will appear dusky or cyanotic during this phase, as apnea occurs during this phase. Urinary incontinence is common, bowel incontinence is less common. In addition, the pupils dilate and are unresponsive to light. The tonic phase generally lasts less than 1 minute.




Frontal lobe epilepsy

  • Many overlapping syndromes with frequent brief attacks (<30 secs)

  • Simple-complex seizures

  • Focal motor seizures (from motor strip)

  • Supplemental area motor seizures

  • Tonic and postural signs and symptoms with preserved consciousness; frequent falls

  • Complex partial seizures

  • Complex motor activity, vocalization, and gestural automatism (may be sexual)

  • Common to proceed to secondarily generalized tonic-clonic seizures

Mesial temporal lobe epilepsy

  • Most common cause is hippocampal sclerosis

  • Mostly complex partial seizures with automatisms and psychic symptoms

  • Often preceded by an aura in 50-95% of patients; rising epigastric discomfort is the most common aura

  • Seizure may include


    oral or manual automatisms

    olfactory and auditory illusions or hallucinations

    unilateral dystonic posturing

Parietal lobe epilepsy

  • Usually simple, complex, and secondarily generalized seizures

  • >75% have somatosensory auras

  • May have a distorted body image, visual or auditory hallucinations

  • Usually proceeds to impaired consciousness and contralateral motor activity

Occipital lobe epilepsy

  • Most have visual auras

  • Elemental visual hallucinations (e.g., flashing lights, colored lights) or sometimes blindness, scotoma, or hemianopsia

  • Eye blinking, nystagmus, head deviation, tonic and clonic eye movement common

  • Visual phenomena usually contralateral to side of the seizure

  • Often progress to complex partial seizures or secondarily generalized seizure depending on pathways stimulated




Focal and Generalized

For seizures

Focal (previously “partial”): the first clinical and electroencephalographic changes indicate initial activation of a system of neurons limited to a part of one cerebral hemisphere.

Generalized: the first clinical changes indicate initial involvement of both hemispheres.

For epilepsies

Localization-related (focal, partial): epilepsies with focal seizures.

Generalized: epilepsies with generalized seizures.

Focal seizures are conceptualized as originating at some point within networks limited to one hemisphere.

Generalized seizures are conceptualized as originating at some point within and rapidly engaging bilaterally distributed networks.

These terms were abandoned as overarching categories for classifying epilepsies per se, as many syndromes include both seizure types; they may still apply in some but not all instances.


Idiopathic: there is no underlying cause other than a possible hereditary predisposition.

Symptomatic: the epilepsy is the consequence of a known or suspected disorder of the central nervous system.

Cryptogenic: this refers to a disorder whose cause is hidden or occult. Cryptogenic epilepsies are presumed to be symptomatic.

Genetic: the epilepsy is, as best as understood, the direct result of a known or presumed genetic defect(s) in which seizures are the core symptom of the disorder. This attribution must be supported by specific forms of evidence.

Structural/metabolic: there is a distinct other structural or metabolic condition or disease that has been demonstrated to be associated with a substantially increased risk of developing epilepsy. These disorders may be of acquired or genetic origin. When of genetic origin, there is a separate disorder interposed between the gene defect and the epilepsy.

Unknown: the nature of the underlying cause is unknown; it may have a fundamental genetic basis (e.g., a previously unrecognized channelopathy) or it may be the consequence of an unrecognized structural or metabolic disorder not yet identified.

Focal Seizure Types

Complex partial: with impairment of consciousness.

Simple partial: consciousness not impaired.

Secondarily generalized (Note: this was not the terminology used in the 1981 document but has come into common use).

No specific classification is recommended. Seizures should be described accurately according to their semiologic features without trying to fit them into artificial categories.

Organizational Structure for Epilepsies

Hierarchically organized by localization-related, generalized, and undetermined. Within those groups, by etiology (idiopathic, symptomatic, cryptogenic).

No specific organization is proposed. Instead, a flexible approach depending on needs is advocated.

From: Berg, A. T., & Scheffer, I. E. (2011). New concepts in classification of epilepsies: Entering the 21st century. Epilepsia, 52(6), 1058-1062.

The clonic phase begins with a gradual transition from the tonicity of the tonic phase. Inhibitory neurons of the cortex, anterior thalamus, and basal ganglion nuclei become active, intermittently interrupting the tonic seizure discharge with clonic activity. The clonic phase is characterized by violent, rhythmic, muscular contractions accompanied by hyperventilation. The face is contorted, the eyes roll, and there is excessive salivation with frothing from the mouth. Profuse sweating and a tachycardia are common. Color returns to the face. There are times when the patient experiencing an event, has a cessation in breathing and temporality stops. Once the breathing resumes, color returns to the face.

In the postictal phase, the clonic jerking gradually subsides in frequency and amplitude over a period of about 30 seconds, although it may be longer. The involved cells cease firing. The extremities are limp, breathing can be quiet or loud due to airway obstruction, and the pupils, which may be equal or unequal, begin to respond to light. Upon awakening, most patients are confused, disoriented, and amnesic for the event. Headache, generalized muscle aching, and fatigue are common. If undisturbed, the patient often falls into a deep sleep for several hours. There may also be temporary paresis, aphasia, or hemianopia. Following a seizure (i.e., generalized or partial), focal weakness, called Todd’s paralysis, may occur and last up to 24 hours. If it occurs, the focal deficit is important in localization of a focal epileptogenic site.

Because the seizure frequently occurs without warning, it is possible for injury to be sustained from falls or other accidents related to the seizure. Head injury, fracture of the limbs or vertebral column, burns, and shoulder dislocations are examples of serious injuries that may occur as a result. Tonic-clonic seizures may occur at any time of the day or night, whether the patient is awake or asleep. The frequency of recurrence can vary from hours to weeks, months, or years.

Status Epilepticus

Although there are many definitions of status epilepticus, it is generally defined as continuous seizures lasting longer than 5 minutes or two or more seizures without complete recovery in between. The most common cause of status epilepticus is abrupt discontinuation of AEDs. Other causes include alcohol withdrawal, acute neurological illness, metabolic disorders, or stroke. There are some forms of status epilepticus that tend to occur in the ambulatory settings, which will be discussed briefly here. A more in-depth review of convulsive status epilepticus and treatment will be found later in the chapter.

Absence Status Epilepticus

Absence status epilepticus is a prolonged confusional state in which the patient can function to some degree and is associated with generalized discharges on EEG that can last from hours to days. It occurs in those with idiopathic generalized epilepsy and has been referred to as spike-wave stupor, petit mal status, and absence status. It is seen in the outpatient setting; it is not life threatening. Absence status epilepticus is treated with benzodiazepines given by the intravenous (IV) route in the ED. An EEG is useful to the diagnosis and response to treatment and maintenance of current AEDs to prevent further episodes.10, 11

Simple Partial Status Epilepticus

Patients with simple partial status epilepticus (SPSE) present with focal, uncontrolled motor movements or sensory distortions such as déjà vu, imaginary sights, smells, tastes, or imaginary sounds, depending on the location of the seizure focus. The individual has preserved awareness during the event, which can be treated with a benzodiazepine and routine AEDs.12

Complex Partial Status Epilepticus

Patients with complex partial status epilepticus have impairment of consciousness or appear to be in an altered state of awareness of their environment. They exhibit strange behavior, and the duration of the seizure can be long, sometimes lasting for days. The seizure focus is commonly the temporal lobe; history and EEG can confirm diagnosis. Treatment with a benzodiazepine will usually break the seizure, and maintenance with traditional AEDs is recommended.10

Epileptic Versus Nonepileptic Events

Seizures may also be classified as either epileptic or nonepileptic in nature. Epileptic seizures include partial and generalized seizures discussed earlier. Nonepileptic seizures or nonepileptic events number close to 30% of referrals to epilepsy centers. The clinical presentation often resembles that of an epileptic seizure, yet they fail to respond to standard treatment with AEDs because they are not epileptic. Nonepileptic events can be physiologic (seizures due to syncope) or psychogenic nonepileptic seizures (PNES). Patients have often failed trials of multiple AEDs and other treatments used to treat epilepsy and this should be a clue that a misdiagnosis has been made and further studies are required to characterize events.

Psychogenic Nonepileptic Seizures (PNES)

It is noted that PNES are more common in females and in those women with a history of physical, sexual, or emotional abuse; they are present without any evidence of an underlying pathological condition. The current understanding of PNES is that it is a conversion disorder which occurs on a subconscious level where the primary gain for expression of repressed trauma is that of anxiety relief. Secondary gains may be present and can include time off from work, kindness, attention and concern from an abuser, and release of responsibilities. Some believe that PNES is a form of dissociation and is now being seen in veterans returning from war with posttraumatic stress disorder. Other comorbidities seen with PNES include depression, anxiety, PTSD, and other somatoform presentations. Those who have confirmed epilepsy can also experience PNES, which makes treatment challenging. The prognosis is worse the longer the problem continues without treatment; it takes on average 7 years to diagnose the disorder.13

The term pseudo seizure has been used in the past and should be discouraged because it implies that one is “faking” a seizure. It is not to be confused with malingering, which is feigning a mental or physical disorder in order to avoid something such as going into the military, or to achieve something such as compensation for involvement in a motor vehicle accident. Malingering is intentional and cases are rare.

The diagnosis of PNES begins with evaluating the history of seizures, past treatments, and risk factors for PNES. The ictal characteristics of PNES are different from those having epileptic seizures and can include asynchronous body movements with flapping of the extremities, pelvic thrusting, stuttering, screaming, weeping, and often the eyes are closed. Symptoms are often dramatic, can start slowly, and wax and wane over 30 minutes, whereas an epileptic seizure usually has sudden onset with a duration of 1 to 2 minutes.14, 15

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Jul 14, 2016 | Posted by in NURSING | Comments Off on Seizures and Epilepsy

Full access? Get Clinical Tree

Get Clinical Tree app for offline access